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Assessment : Assessment 3 Case Study: Written Case Notes and Management Plan
Length :2000 words (+/- 10%)
Learning Outcomes: The Subject Learning Outcomes demonstrated by successful completion of the task below include:
c) Examine and apply nursing interventions and selected cognitive and behavioural techniques in the care and management of people with mental health conditions SLO
d) Demonstrate appropriate person-centred care including comprehensive documentation and appropriate referral within a multi-disciplinary team.
e) Demonstrate skills in the interprofessional clinical management of specific psychiatric conditions. SLO
g) Demonstrate appropriate person-centred care including comprehensive documentation and appropriate referral within a multi-disciplinary team
Assignment 2 involves the written component of your response to the case scenario that you performed your role play (simulation) in Assessment 1. This task requires you to embrace major mental health concerns or issues identified through MSE and RA in assessment-2, and then develop a detailed management plan considering recovery-focussed multidisciplinary team approach, and therapeutic nursing interventions such as CBT or de-escalation techniques, psychoeducation, psychopharmacological education. You are required to document major issues, nursing interventions and strategies including your communication to other health professionals working in the multi-disciplinary team. This will include written case notes (progress notes) based on your MSE and Risk Assessment findings from Assessment 1, from which you will devise a management plan.
Please refer to the Task Instructions for details on how to complete this task.
Based on the analysis of your findings from MSE & RA conducted for the case scenario in assessment -1 simulation. You are required to write the major mental health concerns/issues along with clinical manifestations and recovery-focussed nursing interventions including multidisciplinary team approach. This will reflect your in-depth and critical knowledge and skills in understanding mental health issues, management approaches, and nurses and multidisciplinary team’s roles.
Concise and accurate communication with the health care team, including doctors, nurses and allied health staff is an important role of the registered nurse. Providing clear communication in the case notes (progress notes), which will include the management plan is crucial to ensure all staff are informed about important details regarding the patient’s presentation and mental state on the ward. This facilitates effective nursing care of patients and protects staff by providing them with all relevant facts relating to the patient.
This assignment will develop your practical skills as a mental health nurse, giving you the training to engage in activities and tasks relevant to everyday nursing practise.
Following on from assessment 1, this assignment involves the written component of your response and management of the case.
You are asked to document the case notes (progress notes) relevant to the case scenario, including management plan. In addition, you will document key details regarding the client that you would provide in the clinical handover that occurs at the end of each shift.
Please complete the following steps relating to the case scenario from assessment 1:
1). Detail nursing impression (out of assessment) and management plan – 1500 words (+/- 10%):
You will need to draw information from the MSE and risk assessment you completed based on the case scenario presented for the role-play in Assessment 1. You focus on patient/consumer’s presentations, their triggers, at least 2 clinical manifestations, immediate and long-term management strategies, including therapeutic nursing interventions (CBT/de-escalation techniques, psychopharmacological interventions) and recovery-focussed multidisciplinary approach.
The interventions you select need to be ones that the nurses can carry out rather than something that you would refer the patient (e.g. electro-convulsive therapy).
The contents under nursing impression and management plan need to reference the sources of your information using APA 7th in order to support the evidence-based nature of your interventions. Referencing does not contribute to the word count.
2). Progress notes/ Nursing notes: 500 words (+/- 10%).
Document all relevant aspects of the case in the case notes (progress notes). Ensure to include all relevant aspects of the MSE, assessment of relevant details relating to the patient’s presentation, relevant safety issues and risk assessment, including strategies nurses would follow to communicate with the consumer/patient. NOTE: You will need to submit the completed MSE and Risk Assessment as evidence in an appendix to your case notes. These documents do not contribute to the overall word count.